Grow Your Potential Registration Form

Personal Information:

• Full Name: ____________________________________________________________

• Date of Birth: ________________ Age: ______________
• Gender Identity: [ ] Male [ ] Female [ ] Transgender [ ] Non-binary [ ] Genderqueer [ ] Two-spirit [ ] Other: ______________ [ ] Prefer Not to Say
• Home Address: _______________________________________________
• City: _____________________________ Postcode: ______________
• Contact Number: ___________________ Email: ___________________
• Emergency Contact Name: ___________________ Phone: ______________

Student Background:

• Previous School (if applicable): ________________________________
• Reason for Enrolling in Alternative Provision: _____________________________________________________________________
• _____________________________________________________________________
• Education, Health, and Care (EHC) Plan: [ ] Yes [ ] No
  • If Yes, please provide details: _____________________________________
• _____________________________________________________________________
• Special Educational Needs (SEN) Statement: [ ] Yes [ ] No
• If Yes, please provide details: ___________________________________________________________________________

___________________________________________________________________________

• Any Known Medical Conditions or Allergies: _________________________

Parent/Guardian Information:

• Parent/Guardian’s Name: ___________________ Relationship: __________
• Parent/Guardian’s Contact Number: ________________ Email: __________

Emergency Contact (other than Parent/Guardian):

• Name: ___________________ Relationship: __________ Phone: ________

Previous Education:

• Schools Attended in the Last 2 Years (if applicable):
  1. Name of School: _______________________ Year Attended: _______
  2. Name of School: _______________________ Year Attended: _______

Additional Information:

• Please list any interests, hobbies, or extracurricular activities: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
• Please list any specific support or accommodations you may require: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
• Please describe any specific goals or aspirations you have:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Consent and Agreement:

• I hereby grant permission for my child to enrol in Grow Your Potential and understand that my child is expected to abide by the rules and regulations of the program.
• I give permission for Grow Your Potential staff to administer first aid and seek medical attention for my child if necessary.
• I consent to receive updates and communications from Grow Your Potential via the provided contact information.
• I acknowledge that it is my responsibility to inform Grow Your Potential of any changes to the information provided on this form.

Signature (Parent/Guardian): ______________________________ Date: ________